Glasgow head injury outcome prediction program: an independent assessment.
Using an independent data set, the utility of the Glasgow Head Injury Outcome Prediction Program was investigated in terms of possible frequency of use and reliability of outcome prediction in patients with severe head injury, or haematoma requiring evacuation, or coma lasting 6 hours or more, in whom outcome had been reliably assessed at 6 to 24 months after injury. Predictions were calculated on admission, before evacuation of a haematoma, or 24 hours, 3 days, and 7 days after onset of coma lasting 6 hours or more. Three hundred and twenty four patients provided 426 predictions which were possible in 76%, 97%, 19%, 34%, and 53% of patients on admission, before operation, 24 hours, 3 days, and 7 days respectively. Major reasons for non-feasible predictions were that patients were paralysed/ventilated as part of resuscitation or management. Overall, 75.8% of predictions were correct, 14.6% were pessimistic (outcome better than predicted), and 9.6% optimistic (outcome worse than predicted). Of 197 patients (267 predictions) whose eventual outcome was good or moderate, 84.3% of predictions were correct. For death or vegetative survival (96 patients with 110 predictions), 83.6% of predictions were correct but for severe disability (31 patients with 49 predictions), only 12.2% were correctly predicted. The utility of the Glasgow Head Injury Outcome Prediction Program compares favourably with other outcome prediction algorithms for patients with head injury. (+info)
High yield criteria for emergency cranial computed tomography in adult patients with no history of head injury.
OBJECTIVES: A recent American study identified clinical factors which effectively predicted those patients who would have significant findings on cranial computed tomography. It was proposed to apply these criteria in a UK setting and to determine whether modifications could be made to improve their efficiency. METHODS: A prospective observational study was conducted over a four month period including all non-trauma adult patients referred from the accident and emergency (A&E) department for urgent cranial computed tomography. Presenting symptoms and signs were analysed for ability to predict clinically significant computed tomography findings, namely: acute infarct, malignancy, acute hydrocephalus, intracranial haemorrhage, or intracranial infection. RESULTS: Sixty two patients were included; 22 (35%) had significant findings on computed tomography. Applying the original criteria (any of: age 60 years or older, focal neurology, headache with nausea or vomiting, altered mental status) to the study population showed that no clinically significant tomograms would have been omitted but only 11% fewer performed. Modifying the criteria by removing "age 60 years or older" and replacing "altered mental status" with a Glasgow coma score <14, still ensured 100% sensitivity and would have resulted in 19% fewer scans being performed. CONCLUSION: Simple clinical criteria can be usefully applied to patients presenting to an A&E department in this country to target patients most likely to have clinically significant findings on urgent cranial computed tomography. (+info)
Sedation with "non-sedating" antihistamines: four prescription-event monitoring studies in general practice.
OBJECTIVES: To investigate the frequency with which sedation was reported in post-marketing surveillance studies of four second generation antihistamines: loratadine, cetirizine, fexofenadine, and acrivastine. DESIGN: Prescription-event monitoring studies. SETTING: Prescriptions were obtained for each cohort in the immediate post-marketing period. SUBJECTS: Event data were obtained for a total of 43 363 patients. MAIN OUTCOME MEASURES: Reporting of sedation or drowsiness. RESULTS: The odds ratios (adjusted for age and sex) for the incidence of sedation were 0.63 (95% confidence interval 0.36 to 1.11; P=0.1) for fexofenadine; 2.79 (1.69 to 4.58; P<0.0001) for acrivastine, and 3.53 (2.07 to 5.42; P<0.0001) for cetirizine compared with loratadine. No increased risk of accident or injury was evident with any of the four drugs. CONCLUSIONS: Although the risk of sedation was low with all four drugs, fexofenadine and loratadine may be more appropriate for people working in safety critical jobs. (+info)
A case of sinus pause due to the proarrhythmia of pilsicainide.
A 74-year-old man received oral administration of pilsicainide, a pure sodium channel blocker with slow recovery kinetics, to convert paroxysmal atrial fibrillation to sinus rhythm and developed loss of consciousness two days later. The ECG monitoring revealed sinus pause with markedly prolonged PQ interval and QRS width. Two days after the drug was discontinued, the duration of the QRS complex was normalized. This drug is rapidly absorbed from the gastrointestinal tract, most of which is excreted from the kidney. The plasma concentration of pilsicainide, although not measured, must have been very high, since his renal function was impaired. When pilsicainide is prescribed in patients with coronary artery disease or renal dysfunction, close attention must be paid to avoid life-threatening arrhythmias due to high plasma concentrations of the drug. This is an interesting case because the proarrhthmia of the drug was not tachyarrhythmia, such as ventricular tachycardia or torsades de pointes, but sinus pause. (+info)
Early predictors of 30-day mortality in supratentorial ischemic stroke patients--first episode.
INTRODUCTION: Prognostic factors following stroke remain to be established. The aim of this study was to determine early prognostic factors related with a 30-day mortality in first episode ischemic stroke patients. MATERIALS AND METHODS: The study group comprised 329 consecutive patients, aged between 33 and 99 years (mean age +/- SD 69 +/- 12.6) admitted within 24 hours following their first supratentorial ischemic stroke, confirmed either by computer tomography (CT) and/or autopsy. The following data were assessed within 24 hours of hospitalization: gender, age, history of diabetes mellitus, history of ischemic heart disease, obesity, the neurological deficit at entry and after one day, level of consciousness at entry and after one day, electrocardiographic dysrhythmia at entry, blood pressure at entry and body temperature on the first day following stroke. We also assessed particular serum biochemical and hematological markers including: hematocrit, fibrinogen concentration, platelet count, white blood cell (WBC) count, gamma globulin level, glucose level, cholesterol level, the erythrocyte sedimentation rate (ESR), and creatinine kinase (CK) level. The end-point for assessment was early death (within 30 days). Statistical analysis consisted of univariate analysis and multiple regression. RESULTS: Univariate analysis demonstrated that an older age, increased neurological deficit at entry and on the next day, decreased consciousness at entry and on the next day, electrocardiographic dysrhythmia, increased body temperature and glucose level, decreased cholesterol level and increased CK level were significantly associated with death after 30 days (p < or = 0.05). During multivariate analysis, only a severe neurological deficit (Scandinavian Stroke Scale < or = 15 points) both at entry and on the next day (OR = 8.3; 95% CI: 2.83-24.35), decreased consciousness within the first 24 hours of hospitalization (OR = 19.2; 95% CI: 2.84-127.77) and electrocardiographic dysrhythmia (OR = 5.2; 95% CI: 2.37-13.77) were associated with death after 30 days. CONCLUSION: A severe neurological deficit lasting 24 hours, decreased consciousness within 24 hours of hospitalization and electrocardiographic dysrhythmia are the most important indicators of 30-day mortality in patients with first-time ischemic stroke. (+info)
Rhinospirography in evaluation of respiratory disorders in patients with central nervous system tumors.
The aim of the study was to define respiratory disorders caused by central nervous system tumors. We investigated 51 patients (31 men, 20 women, mean age 58). They were divided into the following groups: patients with supra-, infratentorial and cranio-vertebral junction lesions. We analyzed: the localization of tumors based on CT and MRI examinations and intraoperative observation, the status of consciousness by GCS scale, neurological status and histological findings. For the estimation of dynamics of the respiratory changes, rhinospirography examination was repeated several times in the course of observation. The alterations of respiration were clearly visible in many cases. We have confirmed that respiratory disorders found by rhinospirography provide a source of important clinical information on the effect of the treatment and prognosis. We have also confirmed that changes in respiration are observed earlier than changes of consciousness. (+info)
Measuring plasma paracetamol concentrations in all patients with drug overdose or altered consciousness: does it change outcome?
OBJECTIVE: To assess whether measuring plasma paracetamol concentrations in all patients with drug overdose or collapse (altered consciousness) changes outcome. METHOD: A retrospective survey was performed of all patients attending the Accident and Emergency Department at Guy's Hospital, London over a 12 month period who had plasma paracetamol concentrations measured (it is hospital policy that patients presenting after any drug overdose, or with a collapse/altered consciousness have a plasma paracetamol concentration). RESULTS: A total of 440 patients were identified who had plasma paracetamol concentrations measured, of whom 411 were eligible for the study. Altogether 115 patients presented after a collapse and paracetamol was detected in four of these. A total of 296 patients presented after a drug overdose-136 denied overdose with a paracetamol containing product and paracetamol was not detected in any of these 136 cases. Of the remaining 160 patients who gave a positive history for overdose with paracetamol, 122 presented within 24 hours and 94 had detectable paracetamol values with 16 cases above the treatment line, 12 presented more than 24 hours after ingestion, and 26 presented with a staggered overdose. One patient died as a result of paracetamol overdose. CONCLUSIONS: This is the first study in the United Kingdom to evaluate the clinical value of routine paracetamol levels in patients presenting to the emergency department after any overdose or a collapse. Taking blood samples for plasma paracetamol estimation in patients who deny taking paracetamol is of little clinical value. However, there is the potential for missing significant paracetamol poisoning in patients presenting with collapse and so screening with a plasma paracetamol concentration is clinically justified in these patients. Such an approach can only be justified in a country in which paracetamol poisoning is prevalent, such as the United Kingdom. (+info)
Type II (adult onset) citrullinaemia: clinical pictures and the therapeutic effect of liver transplantation.
OBJECTIVE: Adult onset type II citrullinemia is an inherited disorder of amino acid metabolism caused by a deficiency of liver specific argininosuccinate synthetase activity. Most of the patients with this disease were reported in Japan and therefore, this disease has not been well recognised outside this country. The detailed clinical pictures of the patients with type II citrullinaemia are reported and their outcomes after liver transplantation referred to. METHODS: Ten patients with this disease were evaluated. Seven of them underwent liver transplants using a graft obtained from a healthy family member. RESULTS: There were six men and four women; the age of onset of encephalopathy ranged from 17 to 51 years. The initial symptom in nine patients was sudden onset disturbance of consciousness, and one patient had long been regarded as having a chronic progressive psychotic illness. High concentrations of plasma citrulline and ammonia were commonly seen on admission. Although brain CT or MRI lacked any consistent findings, the EEG was abnormal in all patients, showing diffuse slow waves. Additionally, in five patients chronic pancreatitis preceded the onset of encephalopathy. After liver transplantation the metabolic abnormalities, including abnormal plasma concentrations of citrulline and ammonia, were immediately corrected and all neuropsychic symptoms soon disappeared, except for impaired cognitive function in one patient. Six out of these seven patients returned to their previous social lives, including work. CONCLUSIONS: The clinical concept of adult onset type II citrullinaemia coincides well with the range of hepatic encephalopathy, and liver transplantation is a very promising therapeutic approach. (+info)